7/31/2019 Shooting Field Trial Permit Application

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FEE $18.00/$35.00

Make Check Payable to DEEP

Wildlife Division

79 Elm Street

Hartford, CT 06106

APPLICATION FOR SHOOTING FIELD DOG TRIAL PERMIT1. Individual/Organization conducting trial:

2. Date of trial: ____________________

3. Type of trial: (check one) ______ a. PRIVATE LAND:FEE:$18 ______ b. STATE LAND:FEE:$35

4. Location where trial will be held:(Property, Street and Town)

5. All shooting field trials held at Nod Brook Management Area, Mansfield Hollow Dam, SugarbrookField Trial Area or Flaherty Field Trial Area must be sanctioned by one of the following: (check one)

______ American Kennel Club (AKC) ______ North American Versatile Hunting Dog Association (NAVHDA)

______ Connecticut Amateur Shooting Dog Field Trial Association (CASDFTA)______ Other (specify) _____________________________________________________

6. Species of birds to be shot at the trial:____Pigeons____Pheasants____Quail_____Chukar Partridge ____Ducks

7. Name and address of breeder from whom birds and/or animals to be used at trial will beobtained*:

(Breeder) (Address)*IF BIRDS ARE TO BE PURCHASED OUT OF STATE, AN IMPORTATION PERMIT MUST BE OBTAINED.

8. Numbers of bands that will be needed: ___________ Band numbers sent: _________($ .20 per band)

9. Person named below agrees to act as the Agent of the Commissioner, band birds shot at thetrial and make out the necessary reports. Any person making a written false statement on this formshall be subject to arrest as provided for in Section 53A-157 of the Connecticut General Statutes asamended.

Name:________________________________ Signature: ___________________________(Please Print)

Address:__________________________________________________________________

Phone #:_________________________________ Email: _________________________10. All permittees using state-owned properties without liability insurance coverage must

complete: Liability/Hold Harmless Waiver

The permittee agrees to indemnify and save harmless the STATE and its officers, agents and employees of any claims,damages, losses, litigation expenses, counsel fees, and compensation arising out of injuries (including death) sustained byor alleged to have been sustained by the officers, agents and employees of the permittee and from injuries (includingdeath) sustained by or alleged to have been sustained by the public or by any other persons or property, real or personal(including property of the permittee) caused in whole or in part by acts, omissions, or neglect of the permittee.

______________________________________________ Date _________________Permittees Signature

A REPORT ON THE TRIAL IS DUE WITHIN ONE WEEK OF TRIAL. APPLICATIONS MUST BESUBMITTED AT LEAST 2 WEEKS PRIOR TO TRIAL DATE.

Rev. 7/12/2011